CHAPTER 2. TRAINING GENERAL. This chapter outlines recommended training for all EMS personnel including flight crewmembers and medical personnel.
a. Flight Crewmember. Because of the circumstances in which EMS work is accomplished, aircraft may be frequently assigned to fly in less than ideal weather conditions; i.e., night, low ceiling and/or low visibility, and into remote areas.
(1) Pilots should undergo regular recurrent training to ensure they will be familiar with all instrument flight procedures authorized on the operator's operations specifications. Since medical flights may use airports with no air traffic control (ATC) assistance, no-radar environment and limited facilities, pilots must be proficient in nonprecision approach procedures.
(2) A training program should be prepared that will address the possibility of a forced landing in a remote area.
The program will address procedures relevant to the evacuation of a patient under extreme conditions related to a forced or precautionary landing.
Training should also address procedures to be followed in the event of a fire or smoke in the cabin either while airborne or on the ground. Particular attention should be paid to the needs of the patient during and after evacuation.
b. Medical Personnel. Medical personnel assigned duty during flight should be instructed in the use of aviation terminology. Medical personnel should use aviation terminology a of instructions iron ex to avoid confusion or misunderstandings of instructions from the flightcrew during the EMS mission.
(1) Medical personnel should also be trained to properly use, remove, and replace medical equipment installed on the aircraft.
(2) Medical personnel should be trained in physiological aspects of flight prior to being assigned duty during flight.
(3) Medical personnel should also be trained in aircraft evacuation and patient loading and unloading.
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NOTE: The training program should consider the particular aircraft being used, and its safety features. A practice evacuation using emergency exits should be accomplished.
Ground crew and other ground personnel (i.e., nurses, paramedics, etc). EMS/A operations require stringent safety precautions around the aircraft especially during loading and unloading. The FAA recommends that each certificate holder develop a training program that encompasses, in addition to their normal training program, at least the following:
(1) Loading and unloading the aircraft.
(2) Use of visual cues for positioning and parking the aircraft (i.e., standard hand signals, communications, etc.).
Medical personnel should be familiar with procedures to direct ambulances and ground equipment to the aircraft.
A program coordinated with local authorities
(e.g., fire and police departments) to deal with aircraft fuel spillage/leaks, aircraft fires, and other situations requiring emergency responses.
(4) Safe handling of oxygen equipment by all involved personnel. All personnel authorized to refill oxygen should be trained in the use of the recommended cascade system. If liquid oxygen (LOX) is to be used, the specific nature of LOX should be addressed.
NOTE: The FAA recommends that this program involve a licensed airframe and power plant mechanic to teach the correct procedures for handling oxygen equipment.
Maintenance Personnel. In addition to meeting the Flight Crewmembers, maintenance personnel should be trained by the manufacturers of the aircraft modification equipment, or in other maintenance training programs approved by the Administrator.
(1) Inspection of installation, as well as removal and reinstallation of special medical equipment, should be a part of this training.
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Supplemental Training. Training on servicing and maintenance of medical oxygen systems, along with characteristics of medical oxygen versus aviator-breathing oxygen, should be included in the training program.
NOTE: Recurrent training is recommended for all maintenance personnel.
Cockpit Resource Management (CRM). The FAA recommends that, when feasible, EMS/A flights be conducted under instrument flight rules (IFR) with two pilots. The FAA also recommends that a training program be established for CRM and use of checklists.
should be trained in "challenge and response" methods of checklist use. First officers should be trained to assist the pilot as directed. Cockpit procedures should be developed that one pilot is designated to fly the aircraft while the second pilot tends to the emergency.
Judgment and Decisions. The decisionmaking process should have input from all elements involved in an EMS operation.
Aeromedical directors, aircraft operators, the flightcrew, medical personnel, and ground crew contribute to this process.
The degree of input from each element depends upon the type and complexity of every mission.
Management personnel, including the aeromedical director, should be familiar with appropriate FAR and FAA guidelines related to safe operations. Management personnel should participate in the certificate holder's training program to gain knowledge concerning EMS/A operations.
(2) An essential element in flight operations is the timely decision to conduct a particular flight (or continue a flight as planned). To reach a decision, each participant in the decisionmaking process must be familiar with aircraft operations pertaining to the mission being planned.
(3) All personnel assigned to EMS should be trained in the operational aspects of each type of aircraft used. Training should include, but is not limited to, the range of each aircraft concerning the number of crewmembers and passengers carried, equipment installed, including carry-on equipment, weather capabilities, safety around aircraft, and safety in airport areas.
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(4) The certificate holder should be thoroughly familiar with the operational characteristics of each aircraft, and the qualifications of each flight crewmember.
Pilot judgment may be defined as: The mental process by which the pilot recognizes, analyzes, and evaluates information regarding himself/herself, the aircraft, and the external environment. Good pilot judgment can be developed as part of a flightcrew training program. Pamphlet DOT/FAA/PM-86/42, Aeronautical Decision Making for Commercial Pilots, is recommended to improve aeronautical decisionmaking.
The pamphlet covers the concepts of judgment and decisionmaking and is designed to be reviewed under the supervision of a flight instructor.
Decisions concerning flight operations should be made by the pilot in command (PIC) or management personnel qualified in accordance with FAR Section 135.39.
does not include medical personnel such as the aeromedical director or chief nurse of an EMS operation.
A final decision to conduct a flight, or to continue a flight as planned, should be made by the PIC based on his/her judgment. The decision should not be based solely upon the condition of the patient.
(8) The final step is the decision to conduct the flight in a safe and timely manner.
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CHAPTER 3. OPERATIONS GENERAL. This chapter outlines recommendations regarding FAR Part 135 EMS operations with airplanes.
a. EMS Flight Following. In order to ensure a safe and orderly accomplishment of an EMS/A mission, each operator should develop a flight following system. The requirements for conducting flights for which no flight plan has been filed are in FAR Section 135.79. EMS/A operations should be conducted using IFR flight plans and procedures, when feasible, to achieve the highest level of safety.
(1) In addition to IFR flight plans, flightcrews should have procedures to notify the flight following center of the specific aircraft departure time and estimated time of arrival at the scheduled destination.
(2) When visual flight rule (VFR) operations are conducted, a procedure should be used to ensure that each operator can safely conduct the entire flight under VFR conditions.
(3) Each EMS operator is urged to devise a system of obtaining weather information for use prior to releasing any flight.
Flight Time and Rest Requirements. . Each operator should maintain records showing compliance with the flight and rest requirements of FAR Part 135.
The certificate holder's manual should include policy regarding pilots on call with the use of remote paging devices. The manual should indicate how the use of these devices impacts duty time limitations.
Operators using paging devices should consult with their respective FSDO when developing their operations manual and operating procedures so they can properly describe the conditions when a paging device will be used.
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c. Each operator should develop a control system for weight and balance that shows the aircraft will be properly loaded and will not exceed limitations during flight. A control system may include the following:
A loading schedule, composed of graphs and tables based on pertinent aircraft data established for use in loading the aircraft in a rapid manner for EMS operations, should be prepared.
average load weights established in accordance with AC 120-27, as revised. If the index system is used, the manual should contain the procedures for using, managing, and updating.
(3) These programs should include assorted aircraft occupant and equipment configurations (i.e., two pilots, two medical personnel, two patients, large carry-on equipment, balloon pumps, oscillators, 30 percent fuel, etc).
d. Instrument Flight Rules. ATC will provide priority handling for EMS flights using the "Lifeguard" call-sign. The AIM states that extreme discretion is necessary when using the term "Lifeguard" and that the call-sign is intended for only that portion of the flight requiring expeditious handling.
operators should encourage their flightcrews to use "Lifeguard" as appropriate in the remarks section of their flight plans and in radio communications with ATC. Additional considerations when planning IFR flights include the following:
(1) Avoid flight in icing whenever possible.
(2) Avoid weather conditions that may induce additional stress on the patient.
(3) Have contigency plan for coordination of ground services if weather causes diversion to an alternate airport.
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CHAPTER 4. SAFETY GENERAL. The commitment to safety must start at the top of an organization. The single most important element of a successful safety program is the commitment of senior management.
Safety cannot be dictated - it must be practiced. Managers must display a prudent safety attitude by being involved in safety training. The following safety program recommendations are unique to EMS/A operations:
Safety Program. The safety program should be developed considering coordination, when necessary, with organizations that may be essential to the safe completion of an air ambulance ng on the note of Eng mission. Depending on the nature of the operation, an operator may coordinate with one or more of the following organizations:
ATC, hospitals, police departments, fire departments, ground apa Po under caving i spend ic the mision adresing topicion and search and rescue organizations.
concerning the aircraft operation.
The certificate holder should designate a safety officer. This individual should be familiar with each aspect of an EMS operation with emphasis on the safety requirements involved in the operation of EMS aircraft. This individual should plan, organize, and disseminate information about the safety program to all involved persons.
c. The program should encompass at least the following areas: Safety in and around aircraft, flight preparation, weather analysis, communication equipment and procedures, facilities, and other areas deemed appropriate by the certificate holder and local FSDO.
The foundation of any safety program is training.
Supervisors and managers are ultimately responsible for the success and safety record of their organization. To achieve sarety, personnel must receive quality instruction in all aspects of their jobs concerning the safest method of accomplishment. Trained personnel are able to recognize hazardous situations and take appropriate action to avoid accidents.
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